Optimizing Quality of Life and Psychological Well-being: A Health Psychologist Looks at Long Term Care

Harry L. Mills, Ph.D.

Introduction

The overriding goal in long term care should be to improve the quality of life for residents and a major feature of quality living is psychological well-being.  There are two sets of factors that must work hand-in-hand to produce psychological well-being.  One is the quality of care provided.  These are the processes of care that are the focus of most quality programs.  Another set of factors, however, too often ignored are the quality-of-life factors that take into account what the residents actually bring to the equation.   For example, coping patterns help residents preserve their individuality and spite of declining health.  We will apply a developmental theory called selective optimization and compensation and discuss how a greater understanding of how older people adapt to the changes of aging can serve to refine quality of care strategies.  Research in Positive Psychology suggests at least 16 specific factors that seem to influence a resident’s is subjective sense of well-being.

Quality Care and Quality of Life

In many cases quality care patterns have a direct impact on resident quality of living. A safe and timely pattern of care with can lead to a sense of security.  Technically proficient healthcare can lead to optimal health and increased levels of functioning.  Personal attention and individualized care programs that engage the individual in their own care lead to a sense of autonomy and self-determination.  Patterns of care which are respectful of individual needs and values into affirm personhood and reinforce the continuity of the self concept. A higher-quality life comes from recognition by caregivers of individuality and respect by caregivers to the right to privacy.  Even for dementia patients there needs to be continuity with the past and respect for the continuation of social roles important to the individual earlier in life.  People are not constituted in a way that allows them to lie in bed hour after hour, day after day, week after week, month after month as the months turn into years.  An environment must provide opportunities for activities appropriate to age and skills no matter what the disability.

Preservation of the Self

Sheldon Tobin in his book Preservation of the Self in the Oldest Years points out that those who design and long-term care must take into account the way older people, particularly those over the age of 85, strive to cope with the stress of changes that threaten their sense of self. He divides the coping methods into two classes: rational coping techniques in less than rational coping techniques. The preservation of the sense of self is served by ensuring residents are involved in affirming meaningful activities.  They need to have at least a measure of control over daily activities and over social interactions. Successful coping with the challenges of advanced age involves a contraction of one's personal space, sense of time and the numbers of people with whom one has significant relationships.  At the age of 30 there are decades of future ahead; at the age of 85 the future is a matter of years. In earlier years a person may associate with hundreds or even thousands of people but in the older years associations may be restricted to family and only the closest of friends. Such constrictions are appropriate ways to cope.  However, Tobin also points out that are less rational coping techniques.  The older person may deny reality completely.  As an example they may continue to believe in their driving ability well beyond the point at which they should recognize this limitation.  The older person may blame others for things rather than admit to themselves that they are vulnerable.  There's no better example of this than in the dementia patient who blames thievery by staff for items they have misplaced or lost. In short, older people will go to great lengths to preserve their sense of self.

Psychological Well-being

Psychological well-being is a subjective point of view defined as person’s cognitive and affective evaluation of life. The dimensions of well-being include a balance between positive and negative affect.  Affect is a psychological term for emotions.  Negative affect involves such emotions as anger, fear and depression.  On the other hand positive emotions include such things as joy and happiness.  If more of our day is filled with positive emotions than with negative we have a sense of subjective well-being. Well-being is also dependent on how well we meet our fundamental human needs.  That includes basic needs like food, shelter and safety.  There can be no sense of positive well-being if we feel hungry or fear for our safety.  However, given that those needs are met higher level needs like autonomy and self-esteem become important to our sense of well-being.  It also seems very important to our sense of well-being that we have a purpose.  For the oldest among us it is just as important to have goals even though it may be necessary to limit those goals as we age.  Those with a sense of positive well-being continue to set goals and pursue those goals. Activities also seem very important as dimensions of psychological well-being.  There may be some constriction in the options available; however, activities within the framework of current skills can make a great difference.  Finally, optimism and hope are essential elements for a positive sense of well-being.

Selective Optimization and Compensation

Paul Baltes of the Max Plank Institute for Human Development in Berlin and his wife Margaret Baltes of the Free University of Berlin have conducted extensive research on what they characterize as ‘Successful Aging’ and they have proposed that success is in part dependent on the selection process in which strengths are optimized and older people learn to compensate for losses in appropriate ways.  For example, they become more discriminating in the choice of activities with which to spend their time and energy.  Interactions with family become increasingly important in that may restrict themselves to a few real friends rather than a large number of acquaintances. Optimization involves building resources needed to cope through self-education and continued learning.  For example memory skills training can help in compensating for some of the losses that are associated with aging. Compensation involves doing whatever is needed to mitigate limitations and losses.  Visually impaired older people use reading machines which magnify the written word.  If they cannot read they can begin to listen to audio books. To avoid falls they can learn to use a walker, a wheelchair or a cane. To the extent that quality care processes facilitate selective optimization and compensation residents in long term care are more likely to experience a positive sense of well-being in spite of losses.

Psychological Well-being Factors

There are sixteen factors that contribute significantly to a resident’s sense of subjective well being in Long Term Care settings:

Control

Mindfulness/Flow

Calming

Wisdom

Modulation

Communication

Optimism

Joy

Humor

Music

Movement/Exercise

Connectedness

Time Perspective

Remembrance

Spirituality

Purpose

We will briefly discuss each.

Support Optimized Control and Autonomy

People need optimal autonomy and need to believe they exert some control over their world.  As patients move from independent living into the different levels of long-term care they lose the kind of control over daily routine and has been a part of their life.  As we age we shift from primary control in which we actually can act to change our environment and solve problems directly into secondary control in which we are increasingly required to change our reaction in emotional response in order to maintain an emotional even keel.  To maintain a sense of well-being in long term care patients must learn to balance control with acceptance.  As dependency increases due to chronic and acute illnesses and patients exert less and less direct control.  We need to help the patient's compensate by shifting to secondary control and acceptance when conditions cannot be changed.  While there is an understandable inclination to take over all aspects of care and at times for purposes of safety that may be required it is important to keep the patient making choices and feeling as autonomous as is possible.  The number of choices becomes more constricted and the patient has fewer options from which to choose;  caregivers need to allow patients to select from that narrower range.  Even for dementia patients we can give them several clothing options from which to choose rather than deciding it for them.  We can provide them with a calendar of activities and allow them to make choices from the list.  We can engage them in selection from food options.  A positive sense of well-being and the quality of life that attends that sense, is facilitated when we realize the importance of a sense of autonomy and control to every person.

Optimize opportunities for humor

We have all heard that laughter is the best medicine and research on psychological well-being has tended to support the notion. We know that laughing increases the oxygen levels to the brain is in this in turn can improve our perception and awareness.  Laughter releases endorphins which are the feel-good hormones in the brain that increase our sense of well-being for a while.  There is also increasing evidence that laughing improves immune system functioning.  As this evidence has accumulated we understand better and better the experience of Norman Cousins who decided to take his health and his own hands when given a poor prognosis for chronic illness by bringing his favorite comedy movies into his hospital room.  He recovered completely and later was given an appointment at the UCLA School of Medicine for his work on what was called the laughing cure.  To promote a sense of well being in long term care the sounds of disease must be balanced as often as possible by the sounds of laughter.  One of my standard questions now is about my patient's favorite comedy shows on television.  I make a note of when they come on the cable system and do what I can to make sure that we turn CNN off and turn on comedy shows. It would be useful in long term care organizations with stock up on DVDs that can be played for residents individually or in groups.

Optimize opportunities for mindfulness experiences

We all spend at least part of our time being mindful which fundamentally means focusing on exactly what's happening now in our lives.  However we also spend a good part of our mental life regretting the past and anticipating the future with some anxiety.  Older people who have been through acute illnesses, surgery and other health-related trauma can spend too much time reliving those from and ruminating about a future that remains ambiguous at best.  Each of us need those kinds of restorative experiences each day.  There is an active way to attain that state of mind and there is a more passive way through what is called meditation.  Those are two pathways to the same restorative experiences.  Many creative activities such as painting can lead to the mindful experience.  We can tell when we have been three because we lose track of time and totally concentrate on what we do.  Games, including checkers, chess or card games can lead to the same kind of experience. The key seems to be that whatever we're doing must be within our skill range but we need to stretch a bit to attain a goal.  Rhythmic activity like walking can also lead the mindful experience if one focuses on  breathing or changes in muscle activity with each step.  Any activity requiring concentration can be a door to mindful attentiveness.  There are also many activities that would be considered pure play that can lead to the same kind of experience.  Many dementia units provide Montessori types of activities that are simple and repetitive. They can be helpful.

Optimize availability of music and rhythmic movement

Music, they say, has the power to soothe the savage breast.  In the era of brain imaging studies we are increasingly able to identify the impact of music on different areas of the brain and we are learning that can be of major value in enhancing emotional self-regulation.  We know that high pitched musical sounds tend to make us happy and we can actually see that happen with brain imagery as the areas of the brain associated with positive emotions light up. We know that low pitched sounds can do make us sad. We know that music with a faster beat heightens alertness and arousal levels.  And we now know that slow music has a buffering effect on our stress response system.  Studies of blood chemistry have shown that listening to music as a direct impact in reducing stress hormones.  Researchers have found that the human heartbeat tends to synchronize with music experienced by the individual.  Other researchers have found changes in electrical rhythms in the brain when music is being played. With every new resident we should evaluate their musical preferences.  Studies have shown that even those who say they do not care for music and would not arrange it on their own still show significant physiological changes in appropriate music is played.  Dementia patients continue to show physiological responses to music strongly suggestive of that aspect of memory continues to work long after linguistic patterns have declined.  Finally, we should arrange for rhythmic movement attuned to the sound of music since that tends to rivet attention to the sound.  Patients regularly exposed to music report much higher levels of positive well-being.

Optimize calm and deep relaxation each day

Anxiety may very well be a much more common symptom in long term care than depression, although depression is much easier to detect.  A variety of fears associated with higher risk and medical procedures as well as disability and death are common.  Thus those providing care in long term care settings should assist residents in learning and employing methods of relaxation.  The most common in the easiest method to learn is deep abdominal breathing.  When we are anxious we tend to breathe rapidly high and our chest area. Anyone can learn to breathe more deeply in the abdominal region by simply placing their hand above their navel and making sure the hand rises and falls with each breath. And the simplest form of meditation can be achieved by most anyone by just attending to their breathing and simply returning to the sensations associated with the breathing as thoughts intrude.  The exception to this of course is COPD patients who may need professional help to develop relaxation alternatives.  Another very simple method of deep relaxation is to use the minds ability to visualize.  Anyone can help a resident identify a scene likely to produce feelings of calm.  Perhaps it's lying on the beach listening to the sounds of the surf. Perhaps it's lying by a fast-moving creek listening to the sound of birds singing in the feelings of breeze on their face.  Research has shown that the more sensory detail we build into such visualization experiences the better. There are a number of other methods including body scan in progressive relaxation that may require professional help.

Optimizing body movement and exercise

Our bodies are meant to be more than a pedestal for our heads. Human beings are meant to move until it is a longer possible. Recent research has demonstrated that older people including those in long term care can reap the same health benefits from exercise as younger people.  There is no better place to consider the value of selective optimization and compensation then in this area.  Because of illness or even major events like a stroke the movement options and range of motion may be limited and successful movement such as walking may require compensation, however, we should continue to encourage movement each and every day.  All the different kinds of exercises can be made available to older people than with some creativity on the part of the care providers residents can reap significant benefits.  The value of exercise is nowhere more evident than in maintaining balance in reducing the risk of falls.  Older people can benefit from strength and resistance training although the amount of weight used in the training must be significantly reduced. Aerobic exercises can build cardiorespiratory fitness by elevating than sustaining cardiac activity.  The best form of exercise continues to be the most basic.  And that is walking.  Walking without a walker can be of value but also walking behind their wheelchair or with a walker can also be of benefit. Even when the lower body may not be able to be exercised their number of options and simply use the upper body. No exercise program should ever be started without the approval of the primary care physician.  For cardiac patients a stress test is absolutely essential.

Optimize recognition of wisdom

Wisdom is not about passing multiple-choice tests or is it equivalent to a high IQ. Wisdom involves knowledge when both the cognitive and the emotional are in complete harmony.  An auto mechanic can be very wise while a college professor can be perfectly stupid. Psychologists  John Mayer of the University of New Hampshire and Peter Salovey of Yale coined the term emotional intelligence in 1990. In brief, emotional intelligence is the intelligent use of emotions and the use of emotions to make us more intelligent. An emotionally intelligent individual intentionally makes emotions work for them to guide thinking and behavior. Wisdom is emotional intelligence applied to our own lives.  Baltes argues persuasively that the artful application of selective optimization and compensation is a form of profound wisdom. Wisdom involves knowledge of the pragmatics of living day to day and involves appropriate adjustment to the changes that come with aging.  Adjustment to change requires flexibility and rigidity in the face of change is more stupid than wise. Having a positive outlook can be said to be wise while having a negative outlook is not. Having concern for others is a form of wisdom while total self-absorption is not. Living in constant regret about the past is not wise, while being willing to move on and let go of the past is reflective of wisdom. Living in constant worry about the future is not wise while converting worries into problem-solving is a form of wisdom. It could be argued that one of the tasks of being older is to develop a philosophy of life and then to share that philosophy with younger people. We should encourage them to do so.

Optimize Social Connectivity

Over the last 20 years researchers in areas like recovery from cancer have learned an important lesson and that is that social support can help make us healthier.  Victims of breast cancer were found to have fewer recurrences and longer periods of being cancer free when they were provided with social support groups. However one of the most robust characteristics of individual personality is introversion an extraversion. While we should encourage social exchanges in long term care you need to keep in mind that some people like a balance of activities that includes a certain amount of solitude.  One of the most important elements in social connectivity is social assertiveness.  Some residents may actually need social skills training in order to improve their ability to connect with others.  This may include such things as good listening skills and learning how to express empathy for others. Care providers should make an effort to set up interest groups and opportunities for social exchanges rather than leave it up to the patient to make those connections. Such groups can be as simple as scheduling and time to watch a television program together and then discuss what they saw was one another.  Board games can offer a structure within which significant social interaction can take place. Having specific times when visiting one another in rooms is encouraged, is another way to promote social interaction and social connectivity.

Optimize modulation of negative affect

Persistent patterns of negative affect such as depression and anger can do exacerbate physical illnesses.  We know now for example that heart patients who are depressed are at greater risk of another heart attack and have significantly more problems in recovery. The relationship between hostility and heart attacks has been reasonably well established.  It is important that care providers help modulate or reduce the intensity and frequency of bouts of depression and help patients regulate their anger. Generally the best way to address negative emotions is to replace them with positive emotions and to seek a balance between the two. There are times when medications are required in order to chemically modulate persistent patterns of depression.  This is one area that is important enough that care providers need to have available to them mental health professionals who can work with the patient using such methods as Cognitive Behavior Therapy (CBT). However, one of the best ways to address depression patterns in long term care is with positively reinforcing activities.  Keeping patient's active serves to modulate depression and can prevent recurrence of bouts of depression.  Thus the activity therapists in long term care play much more important role than those steeped in the medical model realize. Finally, professional intervention in the form of anger management may be necessary and should be available to LTC staff.

Optimize perspective on time

The passage of time is matter of perspective. In fact it can be argued that time is a human creation. We all know that when we are occupied time either stands still or speeds up.  When we are bored time slows to a crawl. Throughout most of our lives our reality includes fixing ourselves currently in the context of time.  As we get older we should be able to pull ourselves out of the rat race in which we sell our time to others at an appropriate price.  And yet many older people do not adapt well to change in pacing. Also as we get older our timeframe changes.  There are expanses of time behind this and less and less time ahead of us.  In working with seniors it is important to emphasize the use of time as measured by the consistency of that usage with the patient's primary values.  If the patient is physically capable of doing so writing in diaries or journals can be valuable in putting time and perspective. If writing is not a possibility because of disability there are various audio devices that can enable the patient to record their observations and these can later be transcribed. Calendars should be readily observable with key events appropriately marked and patients should be encouraged to keep their own planning calendar for daily reference. Personal calendars a great place to record goals and upcoming events. Pictures and other memorabilia provide accents about events that are part of the course of the patient's life and they should be encouraged. Patients should be regularly reminded of upcoming holidays and important events in their own life like anniversaries and birthdays.

Optimize expressive and communication skills

Helping patients optimize their communication ability can be helpful in a number of ways such as in sustaining support from others.  However the most critical area will continue to be improving communication with health care professionals. Simply training patients in making requests about to whom they are actually making requests, is what specifically are they requesting and when would they like to request to be fulfilled can be helpful. Patients should be advised to carry lists with them to the doctors office with all of their medications and with the details of when they started a medication and the current dosage levels.  They should also take a list of currently applicable medical diagnoses.  Before any doctors visit they should write out all of their questions of a sheet of paper or have a family member do so.  If they are not capable of assertively expressing themselves to medical staff they should take a family member with them to do so.  Many patients do not realize how important their own description of symptoms can be to the doctor.  For example if they have a pain or discomfort they should write down where it is located. They should describe when the pain actually started and to the extent possible the level of pain at different times of day.  They must be able to describe the sensation as to whether or not it is sharp, burning, throbbing and the like.  They should be able to describe what makes it better than what makes it worse.  They should also be able to describe what they've done to try to alleviate pain and  what has worked.  All this should be in writing before the doctor visit.

Optimize opportunities for remembrance

We should help provide opportunities for remembrance.  As there is a decline in short-term memory the importance of memory of events long past become all the more important to patients.  Remembrance helps define a continuity of the self and creates a coherence in the lives of the patients that can promote positive well-being.  In skilled nursing facilities and assisted living facilities one important step is to be sure that there is memorabilia important to the patient on the walls of the room.  Pictures of important events in the patient's life such as weddings and pictures of children at various stages of development can offer a perfect antecedents for asking the patient about events important to them.  Our job is to be attentive and to listen. All too often once vital signs are taken and medical matters have been attended to care staff pivot and leave the room.  Even a few minutes of listening can be most helpful in promoting positive well-being.  If patients are able to write and particularly if they have access is to word processing, they should be encouraged to write about their lives and to share those writings with family, friends and staff.  If concerned about the capacity to write and there are a wide variety of methods for recording the stories patient would like to tell. The process of remembering and sharing those memories can help patients make sense of their lives.  It can help them with an essential developmental challenge of the senior years and that is accepting their life as it was.  And at the same time they can find meaning it gives them a sense of peace.

Optimize optimism and hope

The greater the optimism and a more hopeful the patient the greater the sense of well-being.  The greater the pessimism and hopelessness the less likely it is the patient will have a sense of well-being and this of course can have a devastating impact on patients with chronic illness.  For example researchers have found a positive correlation between hopelessness and both fatal and nonfatal ischemic heart disease.  Several keys to maintaining hope include helping the patient to find alternative pathways to achieve their goals and express their values. We can help the patient by encouraging the belief that they have within the realm of their control ways to achieve an acceptable quality of living. We know that optimists tend to stay healthier longer and in general have a sense of positive well-being.  Pessimists tend to persist in health damaging behavior and do not play an active role in the management of their house.  Optimists tend to persist while pessimists are often the first to give up.  Optimists are much more likely to try to deal directly with life problems by changing the events that produce the problems in the first place.  Pessimists are left using emotion focused coping methods in which they changed their reaction to events and modify emotional responses. Optimistic patients tend to continue to seek information about their illness and methods of coping with illness and pessimists tend to shut themselves off from new information thus limiting their capacity to cope.

Optimize spirituality

We should distinguish between formal religion and spirituality.  On the whole we should leave the doctrines and rituals of religion to the patient.  However religion can be a context for spirituality and spirituality can promote well-being. Essentially spirituality is the search  for the sacred in our lives. It is the seeking of that which is greater than the individual self.  All the world's major religions provide a framework for that kind of search. It is important that there be an experiential aspect and not simply a ritualistic aspect to the patient's pursuit of spirituality.  This may be in the form of prayer, meditation or both. However the rituals of the patient's religion can add to the sense of coherence and continuity essential for positive well-being. For many of the textual aspects of religion including reading the scriptures can have a very positive influence. For patients with dementia the textual aspects are of less value while at the same time the music associated with their religious life continues to have a positive impact well into the latter stages of dementia. So it should continue to be a part of their lives. For many patients the icons associated with their religion should be prominently displayed in the places where they live if that is what they choose. Psychologists studying the common aspects of spirituality in all religions find that three elements are very powerful. Those elements are forgiveness, gratitude and altruism. Nelson Mandela is reputed to have said that holding a grudge and refusing to forgive is like taking poison and expecting that it will kill your enemy.  We should encourage forgiveness, being grateful for what life is given and compassion for others.

Optimize the simple joys of living

Each and every day we should help patients experience the simplest of joyful moments in order to promote well-being. We should know our patients well enough to know what those joys might be. For example:

Drinking hot chocolate on a cold winter's night.

Listening to a kitten purr.

Listening to a bowl of Rice Krispies.

The gentle sound of wind chimes.

Singing a Christmas Carol

Whistling your favorite tune.

Making a baby giggle.

Feeling a breeze

Listening to music

Petting or walking a dog

Watching the full moon rise.

Listening to the rain fall.

Licking the middle out of an Oreo cookie.

Waking up to the sound of birds singing.

Watching squirrels or birds out the window

They cost little, if any, money and they are all around us.

Optimize purpose by regular goal setting

Patients who set no goals at all are revealing a secret goal and that is to die. Even placement in a skilled nursing facility, which many see it as God's waiting room, may constrain the types of goals that can be set but does not eliminate the need for goals.  We seem to need to have a purpose in our daily lives long after the goals of careers, accumulation of wealth, building a family and making a contribution to our world are behind us. The best way to help the patients set goals is to begin by understanding better what their are essential values may be.  While a patient may not be able to plant a garden; they may be able to contribute to the planting of flowers on the grounds or even growing vegetables. They may not be able to play the piano the way they used to play but they can make contributions to the experience of music for themselves and other residents.  We can help patients by carefully guiding them to setting goals that are both practical and obtainable in their state of health and wherever they reside. We should not accept setting no goals in all.  We may need to help the patient on a daily basis to set goals for some kind of meaningful activity. We can help them set goals for getting holiday cards out to family and friends. We can help them by asking them to look forward to the days and weeks to come forward kinds of things they would like to do that will give their life continued purpose and meaning.